Ob-Gyn Coding Alert

Don't forget to document higher-level codes To avoid incorrectly reporting higher-level new patient visits, you should only pick your E/M code based on the lowest level of any of the three components your ob-gyn documents: history, exam, and medical decision-making.
 
(Editor's note: To aid your coding choice, you may want to look at a grid that breaks down these three elements and tell you what's required for each code. If you'd like a pocket version, care of Melanie Witt, RN, CPC, MA, an independent coding consultant in Fredericksburg, Va., then e-mail Suzanne Leder at suzannel@eliresearch.com.)  Learn What a Higher-Level Code Includes You can use a higher-level E/M code if you meet the requirements with solid documentation detailing history, exam, and medical decision-making.
 
Avoid this pitfall: "What I see in performing audits is the lack of information in the history requirements - specifically review of systems (ROS), and past, family, and social history (PFSH)," says Lynn Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill.

For example: If you use 99203 (Office or other outpatient visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of low complexity), you must have a detailed history, detailed exam, and low-complexity medical decision-making. This means that the provider must document a chief complaint, an extended HPI (history of the present illness consisting of four or more elements or the status of three or more chronic or inactive conditions), an extended ROS (the system directly related to the presenting problem plus additional systems for a total of two-nine systems), and at least one element from the PFSH.

The detailed exam, under 1995 guidelines, requires the ob-gyn to perform an extended examination of the affected organ system or body area plus any additional related or symptomatic areas. This usually translates into an examination of between two to seven organ systems or body areas. Under the 1997 guidelines, you have three choices: examining six systems and documenting two exam elements from each system, documenting 12 elements from two or more systems, or documenting any 12 elements from the defined genitourinary single-system exam. The MDM needs two of these three elements: limited number of diagnoses or management options, limited amount or complexity of data reviewed, and/or risk of complications, says Judy Richardson, RN, MSA, CCS-P, a senior consultant at Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C. Identify Problem Areas for 99204, 99205 The requirements for higher-level E/M codes only increase, and your documentation must reflect that.  For example, the new patient visit 99204 (... a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity) requires an [...]